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Total hip replacement

231 citationsUpdated Sep 2026

Overview

Total hip arthroplasty (THA) is a definitive procedure for hip pathology, with indications spanning young patients under 21 years, where it yields substantial 5-year functional improvements and extremely low revision rates [4], to those beyond the ninth decade of life, where it remains a safe and viable treatment modality [173]. In adolescents, THA is reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable [19]. For younger, active patients under 65 years, mid-term survivorship is excellent [49], with long-term implant survival approximately 94% at 10 years regardless of surgical indication [137]. Uncemented THA is a viable option for elderly patients, demonstrating an excellent rate of implant survival [180]. While females present with worse baseline conditions and show relatively less improvement at 1-year postsurgery compared to males [36], THA in patients with sickle cell hemoglobinopathies provides significant pain relief and functional restoration despite increased medical and surgical risks [45].

Intraoperative complications include periprosthetic acetabular fractures, occurring in 0.2% of primary THA with cemented components and 0.4% with noncemented components [1]. Intraoperative periprosthetic femoral fractures occur in 0.1% to 5.4% of primary THA and 3.0% to 20.9% of revision THA [1]. Clinical outcomes for THA in acute acetabular fractures remain inferior to those for osteoarthritis [29]. Although THA may be considered for younger, active patients with displaced femoral neck fractures based on expert opinion [39], conversion THA remains safe and effective, though clinically relevant improvement takes approximately 3 months compared to 1.6 months for primary THA [159]. Prior hip arthroscopy does not impact subsequent THA functional outcomes [174], and hip arthroscopy itself can yield comparably excellent short-term pain relief when performed with appropriate indications [152]. Setting preoperative patient-reported outcome measure thresholds for THA eligibility did not guarantee clinically successful outcomes [163].

Surgical approach selection is guided by clinical preferences and patient factors, as no specific approach or minimally invasive technique has conclusive evidence supporting faster recovery or long-term implant longevity [168, 179]. THA approaches present distinct efficacy-safety profiles [164]. Implant selection is based on patient needs, anticipated longevity, activity level, bone quality, and surgeon experience, as no single design is appropriate for every patient [6]. Revision of failed hip resurfacing to THA rapidly relieves pain and improves function, with results comparing favorably to standard revision THA [47]. The decision to revise metal-on-metal implants is multifactorial and requires documented, objective clinical indications [2].

Anatomy & Pathophysiology

Bony Anatomy and Vascular Supply

The transverse acetabular ligament extends between the two cotyloid pads at the inferior aspect of the acetabulum [184]. Errant retractor placement inferior to this ligament can damage the obturator artery and vein [184]. The medial femoral circumflex artery is located underneath the quadratus femoris muscle or gluteus maximus tendon [184]. Cutting deep to the quadratus femoris or gluteus maximus tendon risks laceration of the medial femoral circumflex artery [184]. The ascending branch of the lateral femoral circumflex artery passes upward beneath the tensor fasciae latae and is encountered in the space between the tensor fasciae latae and sartorius [184]. This branch is at risk during the direct anterior approach to total hip arthroplasty [184].

Nerve Anatomy and Injury Mechanisms

The sciatic nerve travels closest to the acetabulum at the level of the ischium [184]. The peroneal nerve division is most often involved in sciatic nerve injury because this part of the nerve is closest to the acetabulum [184]. Compression is the most common pathologic mechanism of nerve injury following total hip arthroplasty [184]. Errant retractor placement causing excess compression is the most common reason for sciatic nerve injury during surgery [184]. The lateral femoral cutaneous nerve is more commonly injured with the anterior approach to the hip, with an incidence of up to 20% [184]. Injury to the lateral femoral cutaneous nerve may lead to a painful neuroma or decreased sensation [184]. A hip hematoma from anticoagulation can cause sciatic nerve palsy through compression [184]. The sciatic nerve is involved in 80% of nerve injuries and the femoral nerve in 20% following total hip arthroplasty [184]. Only 35% to 40% of patients who have a nerve injury after primary total hip arthroplasty will have recovery to normal strength [184].

Joint Capsule and Ligaments

The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors [249]. No study has reported type I-III mechanoreceptors in the hip joint capsule, so proprioceptive roles cannot be reliably confirmed [249]. The medial iliofemoral ligament is an important contributor to hip torque at the extreme of motion during external rotation [257].

Biomechanics and Kinematics

Restoration of normal hip biomechanics is a key goal of total hip arthroplasty that favorably affects functional recovery [46]. Abnormal hip and knee joint loading during walking after total hip replacement has a biomechanical background originating from hip geometry reconstruction [124]. Degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum [154]. A combination of radiological leg parameters, especially varus alignment, and deviating kinematics explain the joint moments in the frontal plane during gait after total hip replacement surgery [194]. Hip offset differences greater or less than 5 mm do not significantly change gait patterns [185]. Surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty [185]. A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking [183]. In vivo squatting kinematics suggest no danger of impingement or subsequent dislocation, but excessively large hip flexion and small cup anteversion remain as risks [232]. The reference values for hip range of motion used in previous biomechanical reports may not reflect the actual postoperative anatomic hip range of motion in patients undergoing a standard total hip arthroplasty via the posterolateral approach [229]. Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after total hip arthroplasty following improvement in hip flexion [27]. Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities due to individual pelvic kinematics [226]. The functional orientation of the acetabular component during activities associated with posterior edge-loading differs from those measured when supine due to patient-specific pelvic kinematics [280]. Sagittal pelvic kinematics, but not pelvic incidence, influences the risk of prosthetic impingement or dislocation [258]. The lumbosacral and hip motions were the major contributors to global alignment postural change [222]. The interplay between the hip and spine is dependent on spinal stiffness, pelvic tilt, and dynamic hip positions [206].

Pathophysiology of Failure

Periprosthetic osteolysis is a macrophage-initiated biologic response to submicron polyethylene wear debris [8]. Linear pattern osteolysis is associated with cemented and mechanically unstable components where debris accesses the implant bone interface through the effective joint space [8]. Focal pattern osteolysis involves expansile osteolytic lesions that develop by accessing through areas where implant fixation is incomplete [8]. Aseptic loosening results from a combination of environmental and genetic factors [379]. Aseptic loosening accounts for 75.7% of all total hip arthroplasty revisions [379]. Metallosis is defined as the accumulation and deposition of metallic particles secondary to abnormal wear from prosthetic implants [372]. Metallosis occurs secondary to the release of metal ions and particles from metal-on-metal hip implants [372]. Ions and particles shed from implants can lead to local inflammation of surrounding tissue [372]. Fretting and crevice corrosion may occur in 2% or more femoral stem modular interfaces [8]. Trunnionosis diagnosis is made based on a serum cobalt level greater than 1 ppb and cobalt ions significantly greater than chromium ions [8]. Adverse reaction to metal debris involves a T cell-mediated biologic reaction to metal wear products resulting in synovitis, acute lymphocyte vasculitis–associated lesions, and pseudotumor formation [8]. Mechanical noise incidence is between 0.2% and 17.0% and is increased with acetabular implant malposition [8]. Audible noise has not been associated with implant failure or revision [8]. Increased femoral head size greater than 36 mm is associated with a clinical reduction in dislocation rates but also increased incidence of groin pain and higher polyethylene wear rates among younger and more active patients [8]. There is no benefit in hip range of movement or hip function when head sizes greater than 36 mm are used [241]. Sickle cell disease is associated with early prosthetic loosening due to extended bone infarct disease and a higher risk of periprosthetic joint infection [184]. Ankylosing spondylitis is associated with a higher risk for heterotopic ossification and a higher anterior dislocation rate due to hip hyperextension from fixed pelvic deformity [184]. Parkinson disease is associated with a higher dislocation rate, higher perioperative mortality, higher perioperative medical complications, and a higher reoperation rate [184]. Dialysis is associated with a higher risk of infection and loosening [184]. Fat emboli syndrome occurs with femoral stem insertion when fat and bone marrow emboli are pressurized into the bloodstream [184]. The hallmark findings of fat emboli syndrome are intraoperative hypotension, hypoxia, mental status changes, and petechial rash [184]. Abductor tears are an underappreciated cause of greater trochanteric pain syndrome in postarthroplasty patients [381]. The prevalence of abductor mechanism tears was found to be 20% in patients undergoing total hip arthroplasty for osteoarthritis [381]. The etiology of abductor tears after total hip arthroplasty includes physiological degenerative tearing, iatrogenic failed repair, and postoperative tearing [381]. Multiple mechanisms have been proposed to result in symptomatic iliopsoas tendinitis after total hip arthroplasty [334]. A subset of patients may present with idiopathic iliopsoas tendinitis after total hip arthroplasty without clear radiographic pathology or technical error [334].

Classification

Periprosthetic Fractures

Paprosky: This classification system is used for periprosthetic fractures of the acetabulum associated with total hip arthroplasty [1].

Unified Classification System (UCS): The UCS for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts [208].

Greater Trochanter Fracture Classification: A new classification system for isolated greater trochanter fractures associated with total hip arthroplasty is based on fracture location relative to insertional anatomy [127].

BOSTI Hip: This classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty [165].

Bone Stock and Deficiency

Acetabular Bone Loss Classification: A validated classification system for acetabular bone loss guides treatment and prognosticates outcomes in revision total hip arthroplasty [176].

Femoral Deficiency Classification: A classification system and algorithmic approach guide femoral reconstruction in revision total hip arthroplasty based on the type of femoral deficiency [107].

Bone Stock Deficiency Classification: A classification system and management strategies exist for bone stock deficiency in total hip replacement [151].

Mallory: This classification is used to grade preoperative femoral bone quality in revision total hip arthroplasty [293]. Hips with type-IIIA femoral bone quality according to the Mallory classification had a significantly higher rate of failure secondary to aseptic loosening than hips with type-II femoral bone quality [293].

Heterotopic Ossification

Brooker: The Brooker classification is the most frequently used radiographic grading system for heterotopic ossification after total hip arthroplasty [64]. * Grade I: Defined as islands of bone within the soft tissues about the hip [64]. * Grade II: Defined as bone "spurs" from the pelvis or proximal femur, with at least 1 centimeter between opposing osseous surfaces [64]. * Grade III: Defined as bone spurs from the pelvis or proximal femur with the space between opposing osseous surfaces reduced to less than 1 cm [64]. * Grade IV: Defined as apparent osseous ankylosis of the hip [64].

Modified Brooker: * Grade A: Defined as no bone formation [64]. * Grade B: Defined as bone islands with 1 cm separation between the femur and the pelvis [64]. * Grade C: Defined as ankylosis of hip or bone spurs with less than 1 cm between opposing surfaces [64].

One study reported that the Brooker classification system has low interobserver reliability and little clinical relevance [64].

Implant and Component Design

Modular Hip Taper Surface Finish: A new classification system regarding the surface finish of modular hip taper connections has been presented [155].

Femoral Stem Length: A classification system for the length of femoral stems has been suggested to organize the discussion on stem length [158].

Cementless Femoral Fixation: The basic classification system for cementless femoral fixation consists of six categories, with a separate classification considered for short-stem designs that do not fit into these categories [325].

Preoperative and Patient Classification

Hip-Spine: This classification system guides the use of dual mobility components in patients with spinopelvic pathology to reduce the risk of dislocation [219].

American Society of Anaesthesiologists (ASA): The ASA physical status classification system has been evaluated for its predictive ability on health-related quality of life after total hip replacement [205].

Long-term Unreduced Hip Dislocation: A new classification system for long-term unreduced hip joint dislocation, secondary osteoarthritis, and pseudoarthrosis could help surgeons estimate potential difficulties during total hip arthroplasty [16].

Outerbridge: This classification of the femoral head and acetabulum is used to grade chondral damage in patients undergoing hip arthroscopy [319].

Beck: This classification is used to grade labral damage and transition zone cartilage injury in patients undergoing hip arthroscopy [319].

Stulberg: This classification is used to classify hips in adults who suffered Legg-Calvé-Perthes disease prior to total hip arthroplasty [330].

Tönnis: This grade is used to assess radiological signs of osteoarthritis in patients undergoing total hip arthroplasty [330].

Crowe: This classification is used to categorize developmental dysplasia of the hip in patients undergoing total hip arthroplasty [294].

Ficat: This staging system is used to classify femoral head osteonecrosis in patients undergoing total hip arthroplasty [294].

Garden: This classification is used to categorize intracapsular hip fractures in patients undergoing total hip arthroplasty [294].

Complications and Outcomes

Hip Society: The Hip Society developed a standardized list, definitions, and stratification system for complications of total hip arthroplasty [22].

Modified Clavien-Dindo: This grading scheme is used to grade complications in total hip arthroplasty studies [37]. * Grade I: Complications require no change in the routine postoperative course [37]. * Grade II: Complications require a change in outpatient management [37]. * Grade III: Complications require invasive surgical or radiologic management or procedures under anesthesia [37].

Clinical Presentation

Indications and Contraindications

The primary indication for total hip arthroplasty (THA) is the alleviation of incapacitating arthritic pain in patients older than age 65 years whose pain could not be relieved sufficiently by non-surgical alternatives [7]. Historically, patients aged 60 to 75 years were considered the most suitable candidates, but this age range has expanded since the 1990s [7]. The 1994 National Institutes of Health Consensus Statement concluded that THA is an option for nearly all patients with diseases of the hip that cause chronic discomfort and significant functional impairment [7]. Surgery is justified if, despite conservative measures, pain at rest and pain with motion and weight bearing are severe enough to prevent the patient from working or carrying out activities of daily living [7]. Pain in the presence of a degenerative or destructive process in the hip joint as evidenced on imaging studies is the primary indication for surgery [7]. Patients with limitation of motion, limp, or leg-length inequality with little or no hip pain are not candidates for THA [7].

Absolute contraindications include active infection of the hip joint or any other region and any unstable medical illnesses that would significantly increase the risk of morbidity or mortality [7]. Asymptomatic bacteriuria has not been associated with postoperative surgical site infections and should not be considered a contraindication for THA [7]. A documented patent ductus arteriosus or septal defect is an absolute contraindication for bilateral total hip procedures carried out under a single anesthetic [7]. THA is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone [24]. THA proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia [40]. In the setting of severe symptoms and the absence of advanced osteoarthritis on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA [34].

Preoperative Evaluation and History

Before any major reconstruction of the hip is recommended, conservative measures should be advised, including weight loss, nonopioid analgesics, reasonable activity modification, low-impact exercise, and ambulatory aids [7]. In determining the need for revision of painful THA, the patient must be evaluated to determine whether symptoms are the result of failed THA or other problems, including spinal disease, tumor, vascular occlusion, stress fracture, or complex regional pain syndrome [9]. A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty [17]. Evaluation of the painful hip after total hip replacement requires a careful elicitation of the patient's history and examination to distinguish between intrinsic and extrinsic sources of pain [85]. The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific [81]. There should be a low threshold to conduct a systematic clinical evaluation of patients with metal-on-metal hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment [92]. Patient history, physical examination, and radiological studies provide the surgeon with almost all the data required to stratify a patient according to risk for postoperative THA instability [123].

Pain Localization and Characteristics

Pain location helps localize pathology: * Groin or buttock pain suggests an acetabular or a joint-centered problem [15]. * Anterior thigh pain suggests a femoral-side problem [15]. * Lateral hip pain suggests hip abductor weakness, trochanteric impingement, or inflammation (bursitis/tendinopathy) [15]. * Knee pain may indicate a hip condition, while patient-reported hip pain may be referred from the lumbar spine, abdomen, or retroperitoneum [15].

Temporal patterns indicate specific etiologies: * Early-onset and/or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [15]. * Delayed-onset pain is more likely to be the result of a low-grade surgical infection, late hematogenous infection, bearing surface wear (synovitis, osteolysis, mechanical loosening), or stress shielding and loss of periprosthetic bone [15]. * Start-up pain or pain with prolonged ambulation is associated with weight bearing [15]. * Pain while lying on the side suggests bursitis, abductor weakness, tendinopathy, or tear [15]. * Prolonged drainage after surgery, fever, and chills are suggestive of infection [15]. * A history of hip dislocation suggests instability [15].

Pain associated with loose total hip components typically occurs with the first few steps a patient takes, known as start-up pain [9]. A loose acetabular component usually produces pain in the groin, whereas a loose femoral component may cause pain in the thigh or knee [9]. Females presenting for THA have worse baseline conditions and show relatively less improvement at 1-year postsurgery compared to males [36]. Patients who exhibited rapidly progressive osteoarthritis before undergoing total hip arthroplasty showed worse patient-reported outcomes compared with those who did not have rapid progression [140]. An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty [35]. Osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty [83]. Contemporary THA provides similar clinical benefits across both Crowe I developmental dysplasia of the hip and primary osteoarthritis diagnoses [31]. Adjustments for differences in age and prosthesis choice must be made when the results of hip arthroplasty are studied in different diagnostic groups [11].

Physical Examination Findings

Range of motion assessment includes flexion, abduction, and rotation arcs, with comparison of femoral version to the contralateral hip [15]. Pain with active hip flexion may suggest psoas tendon irritation or anterior impingement [15]. Hip abduction weakness may contribute to lateral hip pain and may originate from a neurologic condition (L5 radiculopathy, sciatic neurapraxia), violation of hip abductors from surgery, or inadequate rehabilitation [15]. Neurologic assessment of motor and sensory function may indicate peripheral nerve injury or concurrent lumbar radiculopathy [15]. Vascular assessment includes checking distal pulses, warmth, and perfusion [15]. The paper details the history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty, including iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology [115].

Imaging Studies

Plain radiographs should be taken in perpendicular planes, with the AP view allowing visualization of the contralateral hip [15]. Radiographic signs of loosening include component migration or subsidence, progressive or complete radiolucency, absence of spot welding, pedestal formation in the femur, and bone stock maintained in the femoral neck with calcar sclerosis [15]. Acetabular osteolysis is characterized by size and location using the Charnley and DeLee classification system (Zone 1 superolateral, Zone 2 central, Zone 3 inferomedial) [15]. Plain radiographs underestimate the severity of acetabular osteolysis [15]. Ancillary radiographs (Judet views) or CT scans are important to assess the integrity of the anterior and posterior columns in acetabular osteolysis [15]. Femoral osteolysis is characterized by size and location using the Gruen classification system (Zones 1 through 7) [15]. CT provides assessment of component position and anteversion, the size and location of bone loss, and the quality and location of remaining bone [15]. MRI with artifact reduction may be useful in identifying soft-tissue lesions around the hip joint [15]. Ultrasonography may be useful in identifying soft-tissue masses around failed implants [15]. Nuclear medicine may indicate the presence of components that are not osseointegrated [15].

Plain radiographs may underestimate bone loss in periprosthetic acetabular fractures [1]. Judet views (obturator and iliac oblique radiographs) may help identify an anterior or posterior column fracture in periprosthetic acetabular fractures [1]. The fracture line in periprosthetic acetabular fractures may be obscured by metallic components [1]. Bone scans may help identify late periprosthetic acetabular fractures not seen on plain radiographs [1]. Bone scans may show areas of increased uptake for 1 to 2 years postoperatively in the absence of fracture [1]. CT is seldom needed for periprosthetic acetabular fractures but may help visualize fractures not identified using other imaging methods [1]. A minimum of two views (AP and lateral) are obtained to help identify the type and extent of periprosthetic femoral fractures [1]. X-rays taken immediately after surgery rarely reveal unknown complications in total hip arthroplasty [26]. Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses [10]. A novel technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain [21].

Laboratory Assessment

An erythrocyte sedimentation rate (ESR) greater than 20 mm/hr suggests an inflammatory state [15]. A C-reactive protein (CRP) level greater than 7.0 mg/L suggests an acute inflammatory process [15]. The CRP level usually normalizes within 3 weeks of surgical intervention [15]. For chronic postoperative joint aspiration, a white blood cell (WBC) count greater than 2,500 cells/mL and polymorphonuclear leukocytes (PMNs) greater than 90% are indicative of infection [15]. For acute postoperative joint aspiration, a WBC count greater than 27,000 cells/mL and PMN values greater than 90% are indicative of infection [15]. Lower PMN values may be considered if the clinical picture supports infection (elevated ESR or CRP level) [15]. The final diagnosis of periprosthetic joint infection was based on the interpretation of the clinical presentation and the preoperative and intraoperative findings rather than on a single test [130]. A diagnosis of periprosthetic joint infection was made when the patient met at least one of three criteria: an open wound or sinus in communication with the joint, a systemic infection with pain in the hip and purulent fluid within the joint, or a positive result on at least three tests where either histological evaluation or intraoperative cultures had to be positive [130].

Specific Clinical Scenarios

Postoperative fracture of the acetabulum should be suspected if groin pain is present after trauma [1]. The incidence of periprosthetic fracture of the acetabulum occurring during primary THA with cemented acetabular components is 0.2% [1]. The incidence of periprosthetic fracture of the acetabulum occurring during primary THA with noncemented acetabular components is 0.4% [1]. Intraoperative acetabular fractures typically occur during cup impaction, especially in older patients or those with poor bone quality [1]. The incidence of intraoperative periprosthetic femoral fracture in primary THA is 0.1% to 5.4% [1]. The incidence of intraoperative periprosthetic femoral fracture in revision THA is 3.0% to 20.9% [1]. Trauma is the most commonly cited cause of periprosthetic fractures of the femur [1]. Early periprosthetic femoral fracture after total hip arthroplasty represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity [146]. Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment [117]. Instability after total hip arthroplasty may be more common than is generally recognized [148]. Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms, leading to delayed treatment and fatal outcomes [145]. The differential diagnosis of persisting unusual symptoms after total hip replacement has to include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses [128]. Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis [132]. A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years [20]. Almost one-third of adverse events following total hip arthroplasty were diagnosed between postoperative days 31 and 90 [33]. Increasing age is the only significant patient characteristic associated with an increased length of hospital stay after primary total hip arthroplasty in a 'fast-track' setting [144]. Patients who present with or whose condition progresses to collapse of the femoral head will require treatment with a standard total hip arthroplasty [108]. Total hip replacement gave complete resolution of the symptoms in 41 patients with failure of Austin Moore hemiarthroplasty [139]. The true incidence of trunnionosis in metal-on-polyethylene total hip arthroplasty is likely underreported due to variable clinical presentations and unclear pathogenesis [147].

Investigations

History and Physical Examination: The clinical presentation of pain following total hip arthroplasty (THA) localizes the pathology. Groin or buttock pain suggests an acetabular or joint-centered problem [15]. Anterior thigh pain indicates a femoral-side issue [15]. Lateral hip pain points to hip abductor weakness, trochanteric impingement, or inflammation such as bursitis or tendinopathy [15]. Weakness in hip abduction may contribute to lateral pain and may originate from a neurologic condition, surgical violation of hip abductors, or inadequate rehabilitation [15]. Early-onset or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [15]. Delayed-onset pain is more likely to result from low-grade surgical infection, late hematogenous infection, bearing surface wear, or stress shielding and loss of periprosthetic bone [15]. If the cause of persistent pain is not obvious after a thorough history, physical examination, and plain radiographic evaluation, further investigation is required [23].

Plain Radiography: Radiographs for evaluation of painful THA should be taken in perpendicular planes, with the AP view allowing visualization of the contralateral hip [15]. Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component [346]. Acetabular osteolysis is characterized by size and location using the Charnley and DeLee classification system, which divides the acetabulum into zone 1 (superolateral), zone 2 (central), and zone 3 (inferomedial) [15]. Femoral osteolysis is characterized by size and location using the Gruen classification system, which defines zones 1 through 7 progressing from proximal/lateral distally to the tip of the implant and back up the medial side to the lesser trochanter [15]. In the setting of periprosthetic acetabular fracture, plain radiographs may underestimate bone loss, and the fracture line may be obscured by metallic components [1]. Judet views (obturator and iliac oblique radiographs) may help identify an anterior or posterior column fracture in this context [1].

Advanced Imaging: CT provides assessment of component position and anteversion, the size and location of bone loss, and the quality and location of remaining bone, and may be useful for creating models for reconstruction or customized implants [15]. Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty [167]. Magnetic resonance imaging can directly evaluate the integrity of metallic components and detect occult fractures of the femoral component even when plain radiographs are normal [199]. MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach [301] and accurately describe adverse local tissue reaction (ALTR) in modular femoral neck total hip arthroplasty [304]. MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and periprosthetic joint infection (PJI) in patients with THA [357]. The combined imaging diagnostic criteria for aseptic loosening of the acetabular cup demonstrate superior diagnostic efficacy compared to single imaging parameters [268]. Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans [220].

Laboratory Assessment: For acute postoperative joint aspiration, a white blood cell (WBC) count greater than 27,000 cells/mL and PMN values greater than 90% are indicative of infection [15]. Lower PMN values may be considered if the clinical picture supports infection, such as an elevated ESR or CRP level [15]. Diagnosis of trunnionosis is made based on a serum cobalt level > 1 ppb and cobalt ions >>> chromium ions [8].

Other Considerations: Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing THA component position to prevent instability and early wear [328]. Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement, positioning the acetabular component within the desired target zone in 97.8% of cases [326]. Patients awaiting THA with combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex [341]. AI-based analyses can accurately and consistently evaluate postoperative THA radiographs [344]. Radiographic evidence of femoroacetabular impingement is common in active patients with hip complaints [364]. X-rays taken immediately after surgery rarely reveal unknown complications [26], and routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA [253]. Over half of patients had osteoporosis; however, only 15.3% of patients had a DEXA scan before THA [361]. Results suggest focusing on preoperative function and radiological osteoarthritis to decide when THA will be most effective [335].

Classification Systems: The Paprosky classification for acetabular bone deficiency includes Type I (rim intact/undistorted), Type II (rim distorted or minor deficiencies supporting cup fixation), and Type III (marked superolateral bone loss with >1/3 rim circumference deficient) [57]. The American Academy of Orthopaedic Surgeons classification for acetabular bone deficiency includes Type 1 (segmental), Type 2 (cavitary), Type 3 (combined segmental and cavitary), Type 4 (pelvic discontinuity), and Type 5 (hip arthrodesis) [57]. The Brooker classification for heterotopic ossification includes Grade I (islands of bone within soft tissues), Grade II (bone spurs with ≥1 cm between opposing osseous surfaces), Grade III (bone spurs with <1 cm between opposing osseous surfaces), and Grade IV (apparent osseous ankylosis) [64]. A modified Brooker classification for heterotopic ossification includes Grade A (no bone formation), Grade B (bone islands with 1 cm separation between femur and pelvis), and Grade C (ankylosis or bone spurs with <1 cm between opposing surfaces) [64].

Treatment

Non-Operative

Conservative measures including weight loss, nonopioid analgesics, activity modification, low-impact exercise, and ambulatory aids should be advised before major reconstruction [7]. Total hip arthroplasty (THA) is indicated for patients with chronic discomfort and significant functional impairment due to hip disease when non-surgical alternatives have failed [7].

Operative

Indications: The primary indication for THA is pain in the presence of a degenerative or destructive process in the hip joint as evidenced on imaging studies [7]. THA is an option for nearly all patients with diseases of the hip that cause chronic discomfort and significant functional impairment [7]. In younger individuals, hip preservation procedures such as femoral or periacetabular osteotomy may delay or obviate the need for arthroplasty [7], and joint-preservation techniques should be utilized in very young patients to facilitate future hip arthroplasty surgery [94]. Arthrodesis remains a viable option for young, vigorous patients with unilateral hip disease, particularly those with osteonecrosis or posttraumatic arthritis [7]. THA in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable [19]. While THA is effective for hip conditions in children, it is associated with a higher than normal incidence of revision surgery [143].

Active infection of the hip joint or any other region is an absolute contraindication for THA [7]. Unstable medical illnesses that would significantly increase the risk of morbidity or mortality are absolute contraindications for THA [7]. A documented patent ductus arteriosus or septal defect is an absolute contraindication for bilateral total hip procedures under a single anesthetic [7]. Asymptomatic bacteriuria is not associated with postoperative surgical site infections and should not be considered a contraindication for THA [7].

THA is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone [24]. THA is feasible for the treatment of the three types of congenital hip disease when appropriate techniques and implants are used [25]. THA for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities [75]. THA can provide significant pain relief, restoration of function, and patient satisfaction in appropriately selected patients with sickle cell hemoglobinopathies [45]. The presence of cerebral palsy is not a contraindication for total hip replacement for a painful deformed or degenerated hip [126]. THA provided systematic alleviation of pain and did not aggravate functional status in non-ambulatory cerebral palsy patients [278]. THA is an attractive solution for non-ambulatory patients with cerebral palsy to relieve pain, but the high complication rate requires caution and a multidisciplinary team approach [291].

THA is a cost-effective option compared to non-operative management in patients 80 years old and older [230]. Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%) [56]. THA may be considered for younger and more active patients with displaced femoral neck fractures based on expert opinion [39]. Primary total hip replacement may be the management of choice in rheumatoid patients and for young patients unsuitable for internal fixation of displaced subcapital femoral fractures [207]. THA with cement fixation provides good early clinical results for femoral neck fracture nonunion but demonstrates problems with durability in younger patients [193]. Conversion of failed hip internal fixation to THA is clinically successful with an elevated risk of complications [211]. THA is a reasonable treatment modality for patients failing nonoperative treatments for labral tears given suboptimal outcomes with hip arthroscopy in the setting of early arthritis [248]. THA is effective for the treatment of the difficult condition of high dislocation of the hip [102]. THA is a highly successful treatment in active patients between forty and sixty years old who have osteoarthritis of the hip [236]. It is strongly recommended to perform THA in ankylosing spondylitis patients with stable disease [110].

Surgical Approach / Technique: The most common surgical approaches for THA include anterior, anterolateral, lateral, posterolateral, and mini-posterior techniques [5]. The direct anterior approach (DAA) is utilized by more than 25% of US surgeons [3]. Large registry and multi-institution studies have shown the direct anterior approach can be performed safely without an increase in complications in experienced hands [3]. Abductor sparing approaches through the Watson Jones muscle interval have gained popularity as an alternative to the DAA with similar lower pain levels and faster recovery [3]. The direct anterior approach uses the distal half of the traditional Smith-Petersen approach and is both intermuscular and internervous [58]. Access to the femur is more difficult with the direct anterior approach, leading many surgeons to use shorter or curved femoral components [58]. The interval for the direct anterior approach cannot be safely extended distally, requiring a separate exposure for patients with deformity requiring osteotomy or removal of previously placed implants [58].

The posterolateral approach is a modification of posterior approaches described by Gibson and Moore [48]. The posterolateral approach can be extended proximally by osteotomy of the greater trochanter with anterior dislocation of the hip [48]. The posterolateral approach can be extended distally to allow a posterolateral approach to the entire femoral shaft [48]. The two-incision technique for THA uses a small direct anterior approach for acetabular exposure and a small posterior approach for femoral preparation [251]. The two-incision technique is technically demanding and requires careful patient selection, preoperative templating, and attention to details to avoid potential complications [87]. The two-incision technique offers the opportunity to obtain the benefits of modern hip arthroplasty with the advantage of a shorter recovery and quicker rehabilitation [87]. Damage to the muscle of the gluteus medius and gluteus minimus was substantially greater with the two-incision technique than with the mini-posterior technique in cadaver studies [270]. Every two-incision total hip replacement caused measurable damage to the abductors, the external rotators, or both in cadaver studies [270].

Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care during total hip arthroplasty [72]. All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty [78]. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience [95]. The direct anterior approach may be comparable to other total hip arthroplasty approaches, but there is no evidence to date that shows improved long-term outcomes for patients [86]. Patients who received primary total hip arthroplasty via the direct anterior approach were more likely to receive revision total hip arthroplasty via a discordant approach compared to other primary approaches [76]. Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function [79]. The surgical approach impacts the component selection in THA [105]. In morbidly obese patients undergoing total hip arthroplasty, the direct anterior approach was associated with shorter operative times [106]. A modified direct anterior approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment [89]. The ASI approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery [103]. Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches [82]. DAA subjects performed better during the immediate post-operative period with lower VAS pain scores on the first post-operative day and more subjects climbing stairs normally and walking unlimited at 6 weeks compared to posterior-lateral approach [254]. There were no significant differences between direct anterior and posterior-lateral approach groups at later time points beyond 6 weeks [254]. The authors continue to use the posterior approach as the main approach for primary total hip arthroplasty [74]. The direct anterior approach has been associated with a higher rate of femoral problems, including fracture and loosening [269]. The posterior approach has been associated with a higher rate of dislocation [269].

Implant Selection: No implant design or system is appropriate for every patient, and selection is based on the patient’s needs, anticipated longevity, level of activity, bone quality, dimensions, implant availability, and surgeon experience [6]. Properly selected and implanted total hip components of most designs can be expected to yield satisfactory results in a high percentage of patients [6]. Porous-coated cementless cup is the preferred choice for acetabular fixation [52]. Porous-coated hemispheric cementless cups have reliable long-term results that are superior to cemented cups [52]. Both cementless and cemented fixation methods are acceptable techniques in primary THA for the femoral component [52]. Cementless stem indications include high-activity-level patients and young male patients [52]. Cemented fixation of the femoral component is preferred in patients with poor bone and/or those with a femoral neck fracture due to lower rate of periprosthetic fracture [269]. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients [162]. In patients older than 65 years of age undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early periprosthetic femur fractures [197]. Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement [210]. The results encouraged the continued use of cementless fixation in total hip arthroplasty based on 15-year results of porous-coated anatomic THA [181]. This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty [153]. Implant survivorship at 2, 5, and 10 years is among the best reported for any total hip system in the world for an uncemented primary THA system [51].

There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients [142]. Utilization of metal-on-metal bearings decreased from 39.2% to 5.5% while the utilization of ceramic-on-polyethylene bearings increased from 6.4% to 52.0% between 2007 and 2015 [3]. In 2015, over 90% of acetabular liners used in primary THA were made of cross-linked polyethylene (XLPE) [3]. Long-term data support a marked decrease in wear, osteolysis, and revision surgery beyond 15 years with XLPE when compared with conventional polyethylene [3]. Because of their reported higher risks, there is no clear indication for modularity with a primary THA, unless the hip center cannot be achieved with a nonmodular stem [42]. Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal THA, leading to expanded contraindications to avoid this device in female patients [135]. We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms [149]. We believe the Corin C-Fit uncemented total hip arthroplasty implant should not be used and patients who have had this form of total hip arthroplasty should be kept under regular review [160]. The incidence of implant fractures in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants [44]. One out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime [44]. A specific fracture pattern occurs around well-fixed polished, tapered, collarless stems that is often underestimated on preoperative radiographs, requiring extensive reconstruction surgery and revision of the hip replacement [217].

Bone ingrowth requires live host bone, an appropriate ingrowth surface on the implant, and initial rigid fixation [269]. Motion of the prosthesis within the bone will lead to fibrous fixation or encapsulation [269]. Hydroxyapatite is an osteoconductive surface coating that may shorten the time to biologic fixation [269]. Femoral stress shielding leads to loss of proximal bone density and results from modulus mismatch between stem and femoral bone [269]. Femoral stem breakage occurs from cantilever bending [269]. Cemented cups fail at a higher rate than cemented stems because the acetabular cup is positioned at an angle relative to the longitudinal axis of the leg, creating shear and tension forces at the cement-bone interface [333]. Cement is strongest in compression and weaker in tension [333]. Young, active patients are thought to have increased risk for failure over time with cement [333]. Cemented stems have lower risk of periprosthetic fracture in patients with poor bone and Dorr C anatomy and are generally considered the “gold standard” for hip fractures [333]. Vacuum mixing is the most common method to reduce cement porosity, which reduces stress points in cement [333]. Pressurization of cement before component insertion enhances cement interdigitation with bone [333]. Pulsatile lavage of bone before cementing allows better cement interdigitation by ensuring clean, dry bone [333]. Stem centralization with a distal stem centralizer maintains a uniform cement mantle and prevents mantle defects [333]. Smooth, highly polished stems are designed to slightly subside in controlled fashion into the cement mantle to distribute load and compress cement into bone [333]. Optimal pore size for bone ingrowth is between 50 and 200 µm [333]. Bone will not grow in deeper than 150 µm from the surface of the porous metal [333]. Optimal metal porosity for bone ingrowth is 40% to 80% [333]. Gaps between metal and bone must be less than 50 µm for bone to grow across [333]. Bone fixation is required with less than 50 µm micromotion [333]. Fibrous fixation occurs with greater than 150 µm micromotion [333]. Implants must be placed upon cortical bone to allow physiologic load transfer to weight-bearing regions of bone [333]. Prior irradiation to pelvis and hip increases risk for aseptic loosening of bone ingrowth/ongrowth implants, and cement fixation may be considered [333]. The press fit technique involves preparing bone such that a slightly oversized implant is wedged into position to generate compression hoop stresses [63]. Grit blasting process creates microdivots with no pores, and bone grows onto the rough surface to stabilize the prosthesis [63]. Fixation strength with grit blast fixation is significantly lower than that with porous coating, and therefore the area of surface coating is greater [63]. Stem settling occurs when initial rigid fixation is not good enough to allow osteointegration in bone ongrowth fixation [63]. Hydroxyapatite is osteoconductive only and allows more rapid closure of gaps between bone and prosthesis [63]. Hydroxyapatite has not been shown to provide a clear clinical advantage or reduce loosening [63]. Optimal thickness for hydroxyapatite coating is less than 50 to 70 µm [63].

Adjuncts: Tranexamic acid (TXA) has become standard-of-care at most institutions performing hip arthroplasty given its well-established benefit in reducing surgical blood loss and subsequent transfusions [14]. Oral TXA was equally effective as IV administration but at a greatly reduced cost [14]. A combined IV and topical application of TXA reduced total blood loss by an additional 200 mL compared with the single IV dose group [14]. No orthopaedic study has yet to demonstrate concern for an increase in venous thromboembolic (VTE) events in the setting of TXA administration [14]. Aspirin continues to increase in popularity for VTE prophylaxis following THA as it is inexpensive, readily available, well-tolerated, requires no monitoring, and has an excellent safety profile [14]. The American College of Chest Physicians directly endorses aspirin as an effective agent for prophylaxis against VTE in THA patients [14].

Complications

Periprosthetic fracture: The incidence of acetabular periprosthetic fracture during primary total hip arthroplasty (THA) is 0.2% with cemented components and 0.4% with noncemented components [1]. Intraoperative risk factors for acetabular fractures include noncemented press-fit components, underreaming by more than 2 mm, elliptical monoblock components, osteopenia or osteoporosis, Paget disease, and removal of acetabular components at revision [1]. Postoperative risk factors include trauma, osteolysis, and osteopenia or osteoporosis [1]. Plain radiographs may underestimate bone loss in these fractures; Judet views (obturator and iliac oblique radiographs) may help identify anterior or posterior column fractures, while bone scans may identify late fractures not seen on plain films [1]. Risk factors for periprosthetic femoral fracture include revision surgery, noncemented press-fit technique, compromised bone stock (osteolytic defect or osteoporosis), and impaction grafting technique [1]. Prophylactic cerclage wires and cortical onlay strut allografts are recommended to reduce the risk of femoral fracture associated with impaction grafting [1].

Long-term fracture incidence: A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons [369]. These fractures are especially frequent in patients with prior total knee or revision total hip replacements [369]. The cumulative incidence of periprosthetic femoral fracture after primary uncemented THA increased in the second decade and reached the incidence of aseptic stem loosening in the third decade [350]. No specific risk factors for periprosthetic femoral fracture were identified in a 20-year follow-up of uncemented THA [350]. In postmenopausal women, hormone replacement therapy (HRT) use before elective THA was associated with lower rates of periprosthetic fracture within 10 years of surgery, without an increased risk of venous thromboembolism [398]. Early periprosthetic femur fractures after primary cementless THA are associated with greater incidences of periprosthetic joint infections and overall reoperations compared to late fractures [405].

Dislocation and Instability: Patients with spinal deformity, those who have undergone spinal fusion, or those with a fixed spinopelvic alignment have a marked increase in the risk of instability [3]. Female patients, patients with osteonecrosis and femoral neck fractures, and those with spinal fusion or limited lumbar spine mobility have an increased dislocation rate [8]. Revision THA carries an increased dislocation risk compared to primary THA [8]. Decreased femoral offset and inadequate leg length restoration can result in femoral neck impingement against the pelvis or acetabular implant, as well as decreased abductor mechanism efficiency due to a reduced moment arm [8].

Implant Design and Instability: Increased femoral head size (>36 mm) has been associated with a clinical, substantial reduction in dislocation rates [8]. However, this design is associated with an increased incidence of groin pain, higher polyethylene wear rates among younger and more active patients, and corrosion and loosening of the head-neck junction [8]. There is no difference in revision rates for dislocation or aseptic causes between dual mobility constructs and large femoral head bearings in primary total hip arthroplasty [363].

Other Considerations: In a series of 309 primary THAs in patients with ankylosing spondylitis, the 20-year cumulative incidence of any revision was 17.5% [327]. Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion [27]. In a prospective randomized study of displaced subcapital fractures, the THA group had a 20% dislocation rate, with five patients suffering recurrent dislocations [314]. In a series of 104 contemporary THAs following prior acetabular fracture ORIF, there were 5 dislocations that did not lead to reoperation and 1 revision for dislocation [323]. In a series of 90 consecutive primary THAs using the ABG II implant, the study population included 87 patients [98]. In a series of 301 dysplastic hips undergoing THA after previous Chiari pelvic osteotomy, the 10- and 20-year survival rates were comparable to primary THA registry rates [401]. In a series of 39 patients with juvenile rheumatoid arthritis undergoing cemented THA, there was a late dislocation of two additional hips that did not recur, one patient required an open reduction of an early dislocation, and one patient required a trochanteric advancement because of recurrent dislocation [324]. In a series of 146 uninfected cemented THAs revised for mechanical failure, postoperative dislocation occurred in 8.2% of cases [318]. In a series of 13 patients undergoing reimplantation after two-stage reconstruction for infection, the hip dislocated in five patients and subluxated in one [295]. In a series of 48 hips undergoing cementless THA with Paavilainen femoral shortening osteotomy for Crowe IV developmental dysplasia, 7 hips (2.1%) underwent revision due to dislocation and 3 hips had dislocations after primary THA that did not require revision [316]. In a series of 17 studies on custom triflange acetabular components in revision THA, the most common complication reported was dislocation at 11% [337]. In a series of 840 hip resurfacing procedures, deep vein thrombosis was the most common early complication, with 86 early complications identified [392]. In a series of 20 patients with total congenital dislocation or marked congenital dysplasia undergoing uncemented THA, no patient had loosening, migration, or revision of the acetabular component, and one femoral component was revised because of aseptic loosening [97]. In a series of 82 hips undergoing cementless primary THA in small Asian patients, the follow-up rate at 10 years was 96.3% [100]. In a series of 96 cases of THA for degenerative hip disease, complications requiring revision included loosening (n=1), deep infection (n=2), dislocation (n=1), and periprosthetic fracture (n=1) [99]. Intraoperative femoral fractures occurred in 4 cases and postoperative femoral fractures occurred in 4 cases during the first 200 two-incision total hip arthroplasties performed by a single surgeon [59]. Uncontrolled intraoperative cracks of the distal femoral fragment were noted in 14 hips (4.2%) during cementless THA with Paavilainen femoral shortening osteotomy for Crowe IV developmental dysplasia [316].

Recovery

Light activity (weeks): Most patients who have had a right total hip arthroplasty recover sufficient hip function to return to driving 4 to 6 weeks postoperatively [111]. With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty [267].

Full activity (months): The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months [156]. Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty [215]. At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively [409].

Rehabilitation protocol: Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized [212]. In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function [247]. A randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required [277]. Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT) [265]. A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty [221]. Short-term recovery favors limited incision over standard incision THA [436]. These data suggest that rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70 [233]. While same-day discharge after primary total hip arthroplasty is associated with low overall readmission rates, smoking and advanced age confer disproportionately greater readmission risk when same-day discharge is pursued [246]. These data suggest that increased travel distance to treatment centers does not markedly impact outcomes following primary THA [243]. We recommend such interventions to be combined with routine care soon after hip replacement [273].

Functional milestones: Maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA [432]. The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes [421]. Functional outcomes improved significantly, with the median Oxford Hip Score increasing from 8 preoperatively to 32 at follow-up [433].

Other Considerations: At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017 [12]. Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty [53]. Although 63% of the original hip replacements were functioning at the latest follow-up or at the time of death, a significant decrease in activity level was seen over time [390]. Patients who had undergone total hip arthroplasty have impaired long-term self-reported physical quality of life and hip functionality but they still perform physically better than untreated patients with advanced hip osteoarthritis [282]. While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients [393]. At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain [261]. After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs [256]. The majority of patients return to work after THA, and some patients are able to start working after surgery [172]. Total hip arthroplasty has positive effects on work capacity in patients who return to work [190]. Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty [187]. Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play [203]. Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation [252]. The majority of patients were able to maintain their physical activity level in the long term after primary cementless THA, compared with the activity level before the onset of restricting osteoarthritis symptoms [244]. Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA [403]. Patients reported higher rates of worsening and lower rates of improvement following revision total hip arthroplasty than primary total hip arthroplasty, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures after revision [54]. Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures [71]. Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years [68]. Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up [417]. Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival [70]. Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup [429]. Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia [434]. Variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution, and surgeons should set realistic expectations, as not all patients achieve optimal results [430]. Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates [431].

Key Evidence

• [L5] The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. [2] (10.5435/jaaos-d-14-00183)
• [L4] Total hip arthroplasty in patients under age 21 years yields substantial improvements in 5-year functional outcomes, regardless of etiology, with extremely low revision rates and excellent implant survivorship. [4] (10.1016/j.arth.2025.03.017)
• [L4] Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses. [10] (10.1016/j.arthro.2009.11.013)
• [L3] Adjustments for differences in age and prosthesis choice must be made when the results of hip arthroplasty are studied in different diagnostic groups. [11] (10.1016/j.arth.2007.03.023)
• [L4] At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. [12] (10.2106/jbjs.20.01235)
• [L4] The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. [16] (10.1186/s12891-020-03678-4)
• [L5] A systematic evaluation involving clinical history, physical examination, laboratory tests, and imaging is required to identify potential differential diagnoses in patients with painful non-metal-on-metal total hip arthroplasty. [17] (10.1016/j.arth.2022.01.063)
• [L3] The findings suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. [19] (10.2106/00004623-199607000-00003)
• [L3] A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years. [20] (10.1186/s12891-019-2646-5)
• [L4] This technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain. [21] (10.5435/jaaos-d-25-01440)
• [L5] [22] (10.1007/s11999-015-4341-7)
• [L5] [23] (10.5435/00124635-200203000-00004)
• [L5] Total hip arthroplasty is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone, supported by early literature demonstrating improved functional and patient-reported outcome scores. [24] (10.2106/jbjs.20.01398)
• [L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. [26] (10.1186/s42836-022-00148-1)
• [L2] Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion. [27] (10.2106/jbjs.21.01127)
• [L4] As clinical outcomes continue to be inferior to those of THA for osteoarthritis, larger multicentre studies are required to investigate possible differences between surgical indications and techniques. [29] (10.1302/0301-620x.107b8.bjj-2024-1232.r1)
• [L3] These findings suggest that contemporary THA provides similar clinical benefits across both diagnoses. [31] (10.1016/j.arth.2026.06.023)
• [L3] Almost one-third of adverse events following total hip arthroplasty were diagnosed between postoperative days 31 and 90, highlighting the importance of looking beyond 30 days when estimating patients' risk of postoperative adverse events. [33] (10.1016/j.arth.2022.10.020)
• [L3] In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA. [34] (10.1016/j.arth.2024.05.043)
• [L2] Compared to osteoarthritis, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. [35] (10.1186/s12891-016-1385-0)
• [L3] THA remains an effective treatment for severe hip osteoarthritis, but females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. [36] (10.1002/ksa.12124)
• [L3] [37] (10.1016/j.arth.2021.02.031)
• [L1] However, total hip arthroplasty may be considered for younger and more active patients based on expert opinion. [39] (10.1016/j.arth.2024.10.085)
• [L4] Nonetheless, total hip arthroplasty proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia. [40] (10.2106/00004623-200402000-00012)
• [L3] Because of their reported higher risks, there is no clear indication for modularity with a primary THA, unless the hip center cannot be achieved with a nonmodular stem. [42] (10.1007/s11999-013-3361-4)
• [L1] The incidence in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants, meaning one out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime. [44] (10.1007/s00264-013-2110-3)
• [L5] Despite increased risks for both medical and surgical complications, total hip arthroplasty in the appropriately selected patient can provide significant pain relief, restoration of function, and patient satisfaction. [45] (10.5435/00124635-200505000-00007)
• [L4] Restoration of normal hip biomechanics is a key goal of total hip arthroplasty that favorably affects functional recovery. [46] (10.1016/j.otsr.2015.11.001)
• [L4] The results compare favourably with those for revision total hip arthroplasty, though longer term results are necessary. [47] (10.1186/1749-799x-5-88)
• [L4] Total hip arthroplasty performed in young and presumed active patients younger than 65 years has excellent survivorship at the mid-term follow-up. [49] (10.5435/jaaosglobal-d-22-00256)
• [L3] The benefits of same-day discharge total hip arthroplasty can be safely extended to the carefully indicated and motivated Medicare patient. [50] (10.1016/j.arth.2019.09.040)
• [L3] Implant survivorship at 2, 5, and 10 years is among the best reported for any total hip system in the world. [51] (10.1016/j.arth.2020.01.063)
• [L4] Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty. [53] (10.2106/00004623-200306000-00013)
• [L3] Patients reported higher rates of worsening and lower rates of improvement following revision total hip arthroplasty than primary total hip arthroplasty, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures after revision. [54] (10.1016/j.arth.2023.05.053)
• [L4] Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). [56] (10.1016/j.arth.2020.10.040)
• [L4] [59] (10.1016/j.arth.2008.09.026)
• [L5] [64] (10.5435/jaaos-d-22-01070)
• [L4] Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years. [68] (10.1007/s11999-008-0566-z)
• [L4] Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival. [70] (10.5435/jaaosglobal-d-25-00115)
• [L3] Primary total hip arthroplasty achieves minimal clinically important difference significantly faster than revision total hip arthroplasty across multiple patient-reported outcome measures. [71] (10.1016/j.arth.2024.10.002)
• [L5] Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care during total hip arthroplasty. [72] (10.2106/jbjs.21.01047)
• [L1] The authors continue to use the posterior approach as the main approach for primary total hip arthroplasty. [74] (10.1016/j.arth.2011.06.007)
• [L5] Total hip arthroplasty for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities and complex techniques. [75] (10.1186/s42836-019-0004-6)
• [L3] Patients who received primary total hip arthroplasty via the direct anterior approach were more likely to receive revision total hip arthroplasty via a discordant approach compared to other primary approaches. [76] (10.1016/j.arth.2023.06.040)
• [L5] All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty. [78] (10.1016/j.arth.2024.10.036)
• [L4] Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function. [79] (10.2106/jbjs.j.01736)
• [L5] The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific. [81] (10.2106/00004623-199710000-00015)
• [L5] Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches, with short-term results being the same as long incisions. [82] (10.1097/blo.0b013e3181468766)
• [L1] Osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty. [83] (10.1007/s00264-010-0979-7)
• [L5] Evaluation of the painful hip after total hip replacement requires a careful elicitation of the patient's history and examination to distinguish between intrinsic and extrinsic sources of pain. [85] (10.2106/jbjs.i.00362)
• [L5] The direct anterior approach (DAA) may be comparable to other total hip arthroplasty approaches, but there is no evidence to date that shows improved long-term outcomes for patients. [86] (10.5435/jaaos-d-20-00334)
• [L5] The two-incision total hip arthroplasty is a technically demanding procedure that requires careful patient selection, preoperative templating, and attention to details to avoid potential complications, but it offers the opportunity to obtain all the benefits of modern hip arthroplasty with the advantage of a shorter recovery and quicker rehabilitation. [87] (10.1097/01.blo.0000192361.00227.6f)
• [L5] This modified approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment, offering a versatile, safe, and accessible option for primary and selected revision total hip arthroplasty. [89] (10.1186/s13018-025-06397-5)
• [L2] There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment. [92] (10.1007/s00264-016-3305-1)
• [L4] Joint-preservation techniques should be utilized to facilitate future hip arthroplasty surgery. [94] (10.5435/jaaos-20-08-487)
• [L1] Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience. [95] (10.1016/j.arth.2016.08.027)
• [L3] [97] (10.2106/00004623-199903000-00006)
• [L4] [98] (10.1016/j.arth.2012.07.022)
• [L3] [99] (10.1186/s12891-021-04980-5)
• [L3] [100] (10.1016/j.arth.2017.04.053)
• [L4] The authors believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip. [102] (10.2106/00004623-199804000-00007)
• [L3] The ASI approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery. [103] (10.1302/0301-620x.96b11.34348)
• [L3] The surgical approach impacts the component selection in THA. [105] (10.1016/j.arth.2023.08.066)
• [L3] In morbidly obese patients undergoing total hip arthroplasty, the direct anterior approach was associated with shorter operative times. [106] (10.1016/j.arth.2026.08.006)
• [L4] The authors present a classification system and algorithmic approach to guide femoral reconstruction in revision total hip arthroplasty, recommending specific implant strategies based on the type of femoral deficiency to ensure stability and osseointegration. [107] (10.2106/00004623-200300004-00001)
• [L5] Patients who present with or whose condition progresses to collapse of the femoral head will require treatment with a standard total hip arthroplasty. [108] (10.2106/jbjs.i.00345)
• [L3] It is strongly recommended to perform THA in AS patients with stable disease. [110] (10.1186/s12891-020-03278-2)
• [L3] Most patients who have had a right total hip arthroplasty have recovered sufficient hip function to return to driving 4 to 6 weeks postoperatively. [111] (10.1097/01.blo.0000072468.32680.ff)
• [L4] The paper details the history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty, including iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology. [115] (10.5435/jaaosglobal-d-25-00226)
• [L3] Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. [117] (10.1016/j.arth.2024.06.002)
• [L4] [123] (10.1016/j.arth.2018.01.047)
• [L2] Abnormal hip and knee joint loading during walking after THR has a biomechanical background originating from hip geometry reconstruction. [124] (10.1016/j.arth.2019.07.027)
• [L4] The presence of cerebral palsy is not a contraindication for either hip arthrodesis or total hip replacement for a painful deformed or degenerated hip. [126] (10.2106/00004623-198668040-00017)
• [L5] This review outlines management strategies for isolated greater trochanter fractures associated with total hip arthroplasty, proposing a new classification system based on fracture location relative to insertional anatomy to inform treatment recommendations for intraoperative, postoperative, primary, and revision settings. [127] (10.5435/jaaos-d-23-00560)
• [L5] The differential diagnosis of persisting unusual symptoms after total hip replacement has to include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses. [128] (10.1007/bf00454733)
• [L1] [130] (10.1186/1749-799x-3-31)
• [L4] Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis. [132] (10.1016/j.asmr.2024.100987)
• [L3] Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal THA, leading the authors to expand contraindications to avoid this device in female patients. [135] (10.1016/j.arth.2011.04.012)
• [L4] Among young THA patients, postoperative complication rates varied by indication; however, long-term implant survival is reassuring regardless of surgical indication—with 10-year survival at approximately 94% for all groups analyzed. [137] (10.5435/jaaosglobal-d-25-00042)
• [L4] Total hip replacement gave complete resolution of the symptoms in 41 patients. [139] (10.1016/s0020-1383(01)00096-1)
• [L3] Patients who exhibited rapidly progressive osteoarthritis before undergoing total hip arthroplasty showed worse patient-reported outcomes compared with those who did not have rapid progression. [140] (10.1016/j.arth.2024.04.016)
• [L2] There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. [142] (10.1302/0301-620x.97b9.34824)
• [L3] THA is an effective form of treatment for hip conditions in children, with a higher than normal incidence of revision surgery. [143] (10.1302/0301-620x.107b5.bjj-2024-0964.r1)
• [L3] Increasing age is the only significant patient characteristic associated with an increased length of hospital stay after primary total hip arthroplasty in a 'fast-track' setting. [144] (10.1302/0301-620x.97b1.33886)
• [Case_report] Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms, leading to delayed treatment and fatal outcomes. [145] (10.2106/00004623-199310000-00020)
• [L5] Early periprosthetic femoral fracture after total hip arthroplasty is not simply the same fracture occurring sooner but represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity. [146] (10.2106/jbjs.26.00128)
• [L4] The review evaluates the incidence, pathogenesis, diagnosis, and treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty, noting that the true incidence is likely underreported due to variable clinical presentations and unclear pathogenesis. [147] (10.1016/j.arth.2018.05.035)
• [L3] Instability after total hip arthroplasty may be more common than is generally recognized. [148] (10.2106/00004623-198264090-00004)
• [L3] We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. [149] (10.1302/0301-620x.99b5.bjj-2016-1232.r1)
• [L5] Classification and Management' by Mnaymneh WA, which provides a classification system and management strategies for bone stock deficiency in total hip replacement. [151] (10.2106/00004623-199072020-00038)
• [L3] Our results show that hip arthroscopy, when performed in patients with the appropriate indications, can lead to comparably excellent outcomes as total hip arthroplasty with significant pain relief at short term follow-up. [152] (10.1016/j.asmr.2022.06.013)
• [L4] This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. [153] (10.2106/00004623-200401000-00014)
• [L4] Current analysis revealed trends that degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum. [154] (10.1016/j.arth.2019.08.057)
• [L5] This study provides an overview on the characteristics and variations of modular hip taper connections and presents a new classification system regarding the surface finish. [155] (10.1016/j.arth.2017.04.027)
• [Paper] The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months. [156] (10.1007/s00402-013-1700-2)
• [L4] The authors suggest a classification system for the length of femoral stems to better organize the discussion on stem length. [158] (10.1302/0301-620x.96b4.33036)
• [L3] Conversion total hip arthroplasty remains a safe and effective treatment choice, though surgeons should counsel patients that it may take approximately 3 months for the median patient to experience clinically relevant improvement compared to 1.6 months for pTHA. [159] (10.1016/j.arth.2025.04.075)
• [L3] We believe this implant should not be used and patients who have had this form of total hip arthroplasty should be kept under regular review. [160] (10.1007/s00402-007-0557-7)
• [L3] While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. [162] (10.1302/0301-620x.104b2.bjj-2021-1199.r1)
• [L3] Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes. [163] (10.1016/j.arth.2022.09.004)
• [L1] THA surgical approaches present distinct efficacy-safety profiles with varying probabilities of advantage. [164] (10.1186/s12891-026-09683-3)
• [L2] The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. [165] (10.1302/0301-620x.106b9.bjj-2024-0529.r1)
• [L4] Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty. [167] (10.1016/j.arth.2008.04.023)
• [L4] There is insufficient evidence to conclusively support the hypothesis that a specific surgical approach or minimally invasive technique provides faster recovery and return to function after total hip arthroplasty, and long-term data do not exist to confirm implant longevity. [168] (10.2106/jbjs.i.00343)
• [L1] The majority of patients return to work after THA, and some patients are able to start working after surgery. [172] (10.1186/s13018-023-03578-y)
• [L3] Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. [173] (10.1016/j.arth.2020.03.026)
• [L3] With the numbers available, prior hip arthroscopy does not appear to have an impact on the functional outcomes of a subsequent THA. [174] (10.1016/j.arth.2016.01.008)
• [L4] The authors present a validated classification system for acetabular bone loss that guides treatment and prognosticates outcomes. [176] (10.1016/j.arth.2007.05.020)
• [L3] For those that qualify after careful selection, outpatient THA might be a feasible alternative to the traditional inpatient THA. [177] (10.1016/j.arth.2019.10.059)
• [L3] We recommend surgeons select the surgical approach for revision THA based on clinical preferences and patient factors. [179] (10.1016/j.arth.2023.01.056)
• [L3] Uncemented total hip arthroplasty is a viable option for the elderly patient with an excellent rate of implant survival. [180] (10.1016/j.arth.2017.01.029)
• [L4] The results encouraged the continued use of cementless fixation in total hip arthroplasty. [181] (10.2106/00004623-200306000-00015)
• [L3] A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking. [183] (10.1007/s00264-009-0855-5)
• [L3] Hip offset differences greater or less than 5 mm do not significantly change gait patterns, and surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty. [185] (10.1016/j.arth.2023.08.040)
• [L3] Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty. [187] (10.5435/jaaosglobal-d-21-00160)
• [L3] Total hip arthroplasty has positive effects on work capacity in patients who return to work. [190] (10.1016/j.arth.2008.11.011)
• [L3] Total hip arthroplasty with cement fixation provides good early clinical results but demonstrates problems with durability, particularly in younger patients and when using first-generation cementing techniques. [193] (10.2106/00004623-200410000-00019)
• [L2] A combination of radiological leg parameters, especially varus alignment, and deviating kinematics explain the joint moments in the frontal plane during gait after total hip replacement surgery. [194] (10.1186/s12891-019-2832-5)
• [L3] In patients older than 65 years of age undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early PPF. [197] (10.1016/j.arth.2023.10.020)
• [L5] Magnetic resonance imaging can be used to directly evaluate the integrity of metallic components and detect occult fractures of the femoral component after total hip arthroplasty, even when plain radiographs are normal. [199] (10.2106/00004623-200401000-00024)
• [L3] Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play. [203] (10.1016/j.arth.2021.04.004)
• [L3] The study utilized data from the Swedish Hip Arthroplasty Register to evaluate the predictive ability of the ASA physical status classification system on health-related quality of life using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years. [205] (10.1186/s12891-020-03399-8)
• [L5] The interplay between the hip and spine is one of the single timeliest topics in the field of hip arthroplasty, dependent on spinal stiffness, pelvic tilt, and dynamic hip positions. [206] (10.1016/j.arth.2018.12.035)
• [L4] The study suggests primary total hip replacement may be the management of choice in rheumatoid patients and for young patients unsuitable for internal fixation. [207] (10.1016/0020-1383(81)90249-7)
• [L4] The Unified Classification System (UCS) for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts. [208] (10.1302/0301-620x.96b11.34214)
• [L1] Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement. [210] (10.3390/jcm8050722)
• [L4] Conversion of failed hip internal fixation to THA is clinically successful with an elevated risk of complications. [211] (10.1016/j.arth.2012.04.003)
• [L5] Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized. [212] (10.1016/j.arth.2024.10.105)
• [L4] Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty. [215] (10.1177/03635465211045698)
• [Paper] A specific fracture pattern occurs around well-fixed polished, tapered, collarless stems that is often underestimated on preoperative radiographs, requiring extensive reconstruction surgery and revision of the hip replacement. [217] (10.1016/j.injury.2011.01.008)
• [L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. [219] (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
• [L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. [220] (10.1302/0301-620x.95b8.31377)
• [L4] A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty. [221] (10.1097/01.blo.0000150127.80647.80)
• [L3] The lumbosacral and hip motions were the major contributors to global alignment postural change. [222] (10.1186/s12891-021-04865-7)
• [L4] Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics. [226] (10.1302/0301-620x.99b2.bjj-2016-0098.r1)
• [L3] The reference values for hip ROM used in previous biomechanical reports may not reflect the actual postoperative anatomic hip ROM in patients undergoing a standard THA via the posterolateral approach. [229] (10.1016/j.arth.2007.02.004)
• [L4] The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients 80 years old. [230] (10.1016/j.arth.2017.11.063)
• [L4] In vivo squatting kinematics suggest no danger of impingement or subsequent dislocation, but excessively large hip flexion and small cup anteversion remain as risks. [232] (10.1016/j.arth.2021.12.028)
• [L3] These data suggest that rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70. [233] (10.1016/j.arth.2023.08.065)
• [L3] Conventional hip arthroplasty is a highly successful treatment in active patients between forty and sixty years old who have osteoarthritis of the hip. [236] (10.2106/00004623-198466050-00014)
• [L2] There is no benefit in hip range of movement or hip function when head sizes > 36 mm are used. [241] (10.1302/2058-5241.3.170061)
• [L3] These data suggest that increased travel distance to treatment centers does not markedly impact outcomes following primary THA. [243] (10.1016/j.arth.2024.10.027)
• [L4] The majority of patients were able to maintain their physical activity level in the long term after primary cementless THA, compared with the activity level before the onset of restricting osteoarthritis symptoms. [244] (10.1111/sms.12482)
• [L3] While same-day discharge after primary total hip arthroplasty is associated with low overall readmission rates, smoking and advanced age confer disproportionately greater readmission risk when same-day discharge is pursued. [246] (10.1016/j.arth.2026.07.054)
• [L1] In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function. [247] (10.2106/jbjs.18.00633)
• [L3] Primary THA can be a reasonable treatment modality for patients failing nonoperative treatments given suboptimal outcomes with hip arthroscopy in the setting of early arthritis. [248] (10.1016/j.arth.2024.07.038)
• [L1] The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors, though nomenclature is inconsistent and proprioceptive roles cannot be reliably confirmed as no study has reported type I-III mechanoreceptors. [249] (10.1371/journal.pone.0229128)
• [L5] [251] (10.5435/00124635-200712000-00004)
• [L4] Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation. [252] (10.1016/j.arth.2006.05.030)
• [L3] Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. [253] (10.1016/j.arth.2022.12.030)
• [L1] [254] (10.1016/j.arth.2013.01.034)
• [L3] After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs. [256] (10.1186/s13018-020-01663-0)
• [L5] The medial iliofemoral ligament was an important contributor to the hip torque at the extreme of motion during external rotation. [257] (10.1016/j.arth.2024.03.044)
• [L4] Sagittal pelvic kinematics, but not pelvic incidence, influences the risk of prosthetic impingement/dislocation. [258] (10.1016/j.otsr.2017.02.014)
• [L4] At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain. [261] (10.1016/j.arth.2025.09.057)
• [L4] Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT). [265] (10.1186/1471-2474-14-91)
• [L2] With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty. [267] (10.5435/jaaosglobal-d-23-00093)
• [L4] The combined imaging diagnostic criteria for aseptic loosening of the acetabular cup after total hip arthroplasty demonstrate superior diagnostic efficacy compared to single imaging parameters. [268] (10.1186/s12891-025-08607-x)
• [L5] [270] (10.1097/01.blo.0000194727.55372.04)
• [L1] We recommend such interventions to be combined with routine care soon after hip replacement. [273] (10.1186/s13018-022-03116-2)
• [L1] This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required. [277] (10.2106/jbjs.16.00674)
• [L4] Total hip replacement provided systematic alleviation of pain and did not aggravate functional status in non-ambulatory cerebral palsy patients, offering a more satisfactory outcome than proximal femoral resection despite a non-negligible rate of complications. [278] (10.1016/j.otsr.2016.07.010)
• [L3] The functional orientation of the acetabular component during activities associated with posterior edge-loading differs from those measured when supine due to patient-specific pelvic kinematics. [280] (10.1302/0301-620x.98b7.37062)
• [L3] Patients who had undergone total hip arthroplasty have impaired long-term self-reported physical quality of life and hip functionality but they still perform physically better than untreated patients with advanced hip osteoarthritis. [282] (10.1186/1471-2474-12-222)
• [L5] Total hip replacement is an attractive solution for non-ambulatory patients with cerebral palsy to relieve pain, but the high complication rate (35%) and risk of revision require caution and a multidisciplinary team approach. [291] (10.1016/j.otsr.2017.02.002)
• [L3] [294] (10.1016/j.arth.2025.02.056)
• [L3] [295] (10.2106/00004623-198971060-00005)
• [L3] MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach. [301] (10.5435/jaaos-d-18-00655)
• [L4] MRI can accurately describe ALTR in modular femoral neck total hip arthroplasty. [304] (10.1016/j.arth.2016.03.022)
• [L1] [314] (10.1016/s0020-1383(00)00125-x)
• [L4] [316] (10.1016/j.arth.2024.04.026)
• [L4] [318] (10.2106/00004623-198567070-00011)
• [L3] [319] (10.1177/03635465241234258)
• [L4] [323] (10.1016/j.arth.2023.11.027)
• [L3] [324] (10.2106/00004623-199701000-00005)
• [L4] [325] (10.2106/jbjs.j.00774)
• [L3] Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement in total hip arthroplasty, positioning the acetabular component within the desired target zone in 97.8% of cases. [326] (10.2106/jbjs.16.01501)
• [L4] In this series of 309 primary THAs in patients with AS, the 20-year cumulative incidence of any revision after primary THA was 17.5%. [327] (10.1016/j.arth.2021.01.054)
• [L5] Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing total hip arthroplasty component position to prevent instability and early wear. [328] (10.1055/s-0039-1697935)
• [L4] [330] (10.1016/j.arth.2024.12.013)
• [L5] [334] (10.5435/jaaos-d-25-00476)
• [L2] Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. [335] (10.1186/s12891-016-1070-3)
• [L4] [337] (10.1016/j.arth.2019.05.032)
• [L2] Patients awaiting THA and having combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex. [341] (10.1016/j.arth.2020.02.029)
• [L4] The AI-based analyses can accurately and consistently evaluate postoperative THA radiographs. [344] (10.1016/j.arth.2026.07.013)
• [L2] Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component. [346] (10.2106/00004623-200411000-00015)
• [L4] The cumulative incidence of periprosthetic femoral fracture after primary uncemented total hip arthroplasty further increased in the second decade and reached the incidence of aseptic stem loosening in the third decade, while no risk factors for the occurrence of a periprosthetic femoral fracture could be identified. [350] (10.1016/j.arth.2017.11.022)
• [L2] MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and PJI in patients with THA. [357] (10.1186/s12891-022-05560-x)
• [L3] Over half of patients had osteoporosis; however, only 15.3% of patients had a DEXA scan before THA. [361] (10.1016/j.arth.2024.10.003)
• [L3] There is no difference in revision rates for dislocation or aseptic causes between dual mobility constructs and large femoral head bearings in primary total hip arthroplasty. [363] (10.1016/j.arth.2021.05.008)
• [L2] Radiographic evidence of FAI is common in active patients with hip complaints. [364] (10.1007/s11999-010-1233-8)
• [L3] A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements. [369] (10.1186/1471-2474-15-168)
• [L5] [372] (10.1007/s40883-021-00222-1)
• [L4] [379] (10.1093/bmb/ldr011)
• [L4] [381] (10.1016/j.arth.2017.04.015)
• [L4] Although 63% of the original hip replacements were functioning at the latest follow-up or at the time of death, a significant decrease in activity level was seen over time. [390] (10.2106/jbjs.m.01573)
• [L4] The study identified 86 early complications in 840 hip resurfacing procedures, with deep vein thrombosis being the most common. [392] (10.1016/j.arth.2012.01.030)
• [L3] While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients. [393] (10.1016/j.arth.2026.04.109)
• [L3] In postmenopausal women, HRT use before elective THA was associated with lower rates of periprosthetic fracture within 10 years of surgery and was not associated with increased venous thromboembolism risk. [398] (10.1016/j.arth.2024.12.020)
• [L3] The 10- and 20-year survival rates of the THA after CPO are comparable to 10-year survival rates of primary THA reported by the registries. [401] (10.1016/j.arth.2020.06.047)
• [L3] Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA. [403] (10.1016/j.arth.2025.11.025)
• [L3] There are greater incidences of periprosthetic joint infections and overall reoperations following early periprosthetic femur fractures compared to late fractures after total hip arthroplasty. [405] (10.1016/j.arth.2023.10.037)
• [L4] At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively. [409] (10.1016/j.arth.2026.05.053)
• [L3] Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up. [417] (10.1016/j.arth.2023.07.019)
• [L2] The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. [421] (10.1302/0301-620x.106b8.bjj-2024-0142.r1)
• [L3] Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. [429] (10.1016/j.arth.2020.09.030)
• [L4] However, variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution, and surgeons should set realistic expectations, as not all patients achieve optimal results. [430] (10.1016/j.arth.2025.11.012)
• [L3] Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates. [431] (10.1016/j.arth.2024.10.008)
• [L3] Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA. [432] (10.1186/s12891-020-3093-z)
• [L4] Functional outcomes improved significantly, with the median Oxford Hip Score increasing from 8 preoperatively to 32 at follow-up. [433] (10.2106/jbjs.25.00876)
• [L3] Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. [434] (10.1016/j.arth.2024.04.060)
• [L1] Short-term recovery favors limited incision over standard incision THA. [436] (10.1007/s11999-012-2717-5)

See Also

• Hip arthroscopy
• Hip resurfacing
• Adverse reaction to metal debris
• Greater trochanteric pain syndrome
• Hip osteoarthritis
• Femoroacetabular impingement
• Periacetabular osteotomy
• Revision hip replacement

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